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Gianna

Coping with the Standards of Care
#26

By Gianna E. Israel
©1998 Gianna E. Israel



GENDERARTICLES This syndicated column by Gianna E. Israel is regularly featured on the 2nd Monday of each month in TG-Forum, the Internet's respected weekly transgender magazine. (http://www.tgforum.com/) Several weeks later each column is forwarded to Usenet transgender groups, readership (Transformatie). GenderArticleAOL's Transgender Community Forum (Keyword "TCF"), and translated for Dutch may be reprinted insofar as each column, introduction and author contact information remains unaltered.

As many of my readers are aware, some of the most heated arguments in our community revolve around the "Standards of Care ." Specifically, those standards written and formally promoted by the membership organization called the Harry Benjamin International Gender Dysphoria Association.(HBIGDA) What is it about that organization and its written standards that evokes such an outcry among transgender men and women? And, how do these standards actually effect you?

If you ask around the community, particularly on the Internet, everyone has an opinion about the subject. This is rightly so because the Standards of Care (SOC) were the first set of guidelines written for the treatment of transsexual persons. They were first authored in 1979, and are typically updated when HBIGDA committees formulate new agreements. As of the present, they are the most widely referred to set of guidelines used for the prescription of hormones, and provision of cosmetic and genital reassignment surgery in transsexuals.

Some of the reasons transsexuals do not like the HBIGDA organization or its Standards of Care are pretty obvious. For a number of years transsexuals were offered no opportunity to provide feedback about how the SOC affected them. In many ways the original drafts of the SOC were written in language so deprecating and disrespectful toward transsexual persons, one would think we were an institutionalized population. It should come as no surprise to anyone that many of the clinical and behavioral scientists who promulgated the SOC did, in fact, first work as forensic experts. In other words, these professional care providers and academics started their careers working and studying sex offenders, deviants and criminology.

Clinically, the SOC have provided a gate keeping function. For better or worse it is all we had for many years. Some lives were saved. Other lives were lost because some people didn't fit into clinical stereotypes or wish to adhere to professional guidelines. Regrettably however, the SOC didn't actually serve to provide any direct education to gender therapists or surgeons. As a SOC member, I am still looking for their monthly or quarterly publication in the mail. At best the organization itself has provided some good networking conventions and a few friends. In my opinion the organization reiterated ideas already in practice which made medical sense, but not always human sense.

There are some transsexuals who dearly adhered to, and continue to love the SOC. In many ways the SOC provided structure in a community where role models were not available to new transgendered persons. Today, those who love the SOC most are people who crave structure. Many of these persons are engineers, lawyers and highly professional people who are accustomed to building on structures and ideas. Consequently during transition they want a master plan to guide the perfect transition and outcome.

I do not look down upon structure. Without it many people's lives would be filled with randomness and chaos. However, in the quest for structure, I have noticed some people carry things too far. They plan out their real life tests (RLT) down to every last detail. They forget how to simply enjoy the process of growing and changing. They also frequently avoid any exploration of ideas and behaviors which challenge current transsexual or transgender stereotypes. Some people need or want to play safe, they can't or don't wish to rock the boat.

I personally enjoy hearing all the complaints about the SOC. Typically, based on the complaint, I can rapidly assess a person. I can gauge how far along that individual is in his or her transition. I can tell if a person is inclined to become involved in activism. A person's background and experience in reading about transgender issues also becomes distinguishable. Finally, it is also often possible to see how that individual accepts or rejects advice from care providers. Surprisingly, I have often found that a person who questions guidelines presented in the SOC is often the same individual who will ask multiple questions about treatment options. Asking questions of care providers is an important part of any process forward, and a healthy attitude toward understanding one's choices in life.

During the mid-1990's my associate Donald Tarver, MD., myself, and a review committee comprised of transgender persons and gender specialists, set out on a journey to write the current book Transgender Care . Within it we developed guidelines, with a goal toward insuring that transgender men and women received competent professional services, yet were not hindered in the pursuit of self-identification as transgender people. One of the things we came to recognize in promulgating new guidelines goes as follows. Guidelines are in fact very much like free advice. You can adopt, reject or reshape guidelines to suit your transition needs. We believe flexibility is a healthy component to any professional relationship, insofar as mental and medical health precautions remain intact.

The preceding comments may seem to be a very cavalier attitude toward our Recommended Guidelines as well as the Standards of Care, however the fact remains that transgender persons are the individuals who must live with the decisions they make. A gender transition is rarely completely reversible for persons who advance beyond a certain stage. The effects of coming out to loved ones or employers are often remembered for the rest of your life. This is true whether you make a transition or not. The effects of taking hormones after approximately a three to six month period become permanent. In all seriousness, it is self-monitored precaution, and discretion, which should govern a person's decisions--balanced with a healthy dose of exploration and willingness to try new things.

Through the course of my practice a lot of people attempt to draw me into arguments regarding the SOC. No thanks. As a busy care provider I don't have time for that, unless I see that harm is being done and nobody is speaking up. I recognize that for the most part SOC and guidelines are for academics, policy makers, and new care providers. Surprisingly, in a recent survey of transgender clients who didn't use the Internet, many had not even heard of the SOC. This group of persons included a number of individuals who had lived as new men and women for many years, they often heard about the SOC just as they were being handed their surgery letters.

What is left open for your opinion is how relative guidelines and standards are to your transition. Must you follow these suggestions as if they are the law? Many people confused them for law, when they are not. Or, must you ignore them completely and declare yourself a gender activist? Many people who take this path disappear within a couple years of transition. I encourage people to balance their personal and community interests. Learn how to discuss your needs with care providers. Seek assistance when you know you should ask for help. Learn how to say no when you are being swayed by someone else's political agenda.

One of the biggest complaints I hear about the SOC as well as those guidelines written into Transgender Care, is the wait period before a person can begin hormones. People feel very angry that they have to wait for anything in today's on-demand world. Receiving hormones is not, however, a process that can be jumped into without preparation. Have you thought about what changes you want? Have you thought about your coming out to others, particularly before the changes become obvious? Have you started electrolysis, chosen a new name, spent any time as a new man or woman? Have you learned which hormones are right for your body type and age group? These are just the beginning of the many questions a person needs answered before starting hormones.

Becoming thoroughly informed about the hormones you want is important. Few doctors are greatly informed about transgender hormone administration. You should be prepared to know exactly what you are asking from your physician. Physicians will frequently ask questions that range beyond asking if you are taking the right step.

Another difficult real life test situation a person can encounter involves asking one's therapist for a letter of recommendation for genital reassignment surgery. Frequently a disagreement will arise if a therapist demands that a client be seen professionally for a full year, even if the client has already lived full-time as a new man or woman for one, two, or many years. This can be quite upsetting to a client who has already set a surgery date, and was not previously aware of the therapist's expectations.

The best way to avoid such a situation is to ask the therapist what his or her policies are for writing letters. Also, throughout the process of transition make certain to document important changes. When you change your driver's license, save the physician's letter used to make that change. When you start hormones, save your referral letter and a copy of your prescription. After all, if you can't afford to see a regular weekly therapist, documenting the process of transition will be useful when are ready to seek independent evaluations and recommendations.

[Those who wish to read theHBIGDA Standards of Care can find themhere.]

Gianna E. Israel provides nationwide telephone consultation, individual and relationship counseling, evaluations and referrals. She is principal author of the Recommended Guidelines for Transgender Care, writes Transgender Tapestry's "Ask Gianna" column; is an AEGIS board member and HBIGDA member.

She can be contacted at (415) 558-8058, at P.O. Box 424447 San Francisco, CA 94142, via e-mail at gianna@counselsuite.com or visit her Web Site

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